Complications

In the hands of experienced bronchoscopists, the complication rate for bronchoscopic intervention in children and adults is reported at less than 5%, with most studies indicating rates of less than 1%. Mortality from bronchoscopic FB retrieval is exceedingly rare and is reported as less than 0.1% [22, 24, 28, 43]. The most common complications associated with FB retrieval include mucosal injury, bleeding, and airway perforation. While extremely rare, post-obstructive pulmonary edema after FB retrieval and perforation which can lead to pneumothorax and/or pneumomediastinum can also occur. Perforations should be managed in a multidisciplinary fashion with interventional pulmonology, thoracic surgery, and/or otolaryngology involved.

Bleeding and Hemoptysis

When patients present with hemoptysis due to FB aspiration, rigid bronchoscopy should be the modality of choice for retrieval. Rigid bronchoscopy allows for superior visualization, stabilization of airway, and better instrumentation options for bleeding and retrieval simultaneously. Remember, minor hemoptysis associated with FB aspiration may foreshadow more signifcant bleeding that can occur during retrieval.

Excessive bleeding during retrieval will likely occur in the setting of FB-associated perforation of the pulmonary or bronchial arterial circulation. Massive intraoperative bleeding during exible bronchoscopic retrieval should lead to aborting the retrieval and stabilizing the patient emergently. In these cases, airway securement is of the utmost importance, whether it is with endotracheal mainstem intubation, balloon blockade of the bleeding airway, or rigid bronchoscopy. Adjunct therapies such as placing the patient in the lateral decubitus position (on side of bleeding) or sedation/paralytics to control coughing can also be utilized. In sub-massive bleeding with relative patient stability, a bronchial blocker balloon may be used in conjunction with securing the airway.

For minor intra-procedure bleeding, topical epinephrine mixed with normal saline (1:10,000 concentration) can be instilled as 2 mL aliquots delivered over the affected area. Keep in mind to avoid topical epinephrine in patients that are elderly or a have history of arrhythmias, carcinoid tumors, and coronary artery disease. Laser therapy, electrocautery, or APC can be used to photocoagulate mucosal irregularities when friable mucosa is observed or bleeding is expected, prior to proceeding with FB retrieval or afterward in the appropriate clinical situations. When bleeding originates from a FB in a distal segmental airway, consider wedging the bronchoscope in the affected airway for 2–5 min to promote clot formation. While technically, clotting time for human blood ranges from 5 to 15 min [59] and bleeding time ranges from 1 to 3 min [60], our recommendations are to frst wedge bronchoscope for 2 min and then reassess. If bleeding persists, then to re-wedge for 4 min and then reassess. Another technique that can be utilized is wedging the bronchoscope into the affected airway and instilling iced saline, which promotes vasoconstriction and applies pressure to the airway mucosa to decrease bleeding, but could affect FB position.

Distal Airway Impaction

Smaller FBs have a tendency to migrate into segmental and subsegmental airways. Impaction of these FBs can occur because of specifc FB properties such as their texture and shape.Additionally, impaction may occur as a result of a weak cough re ex or anatomic variations, which may not be conducive to proximal movement of the FB. As always, care must be taken with retrieving sharp FBs. Prior to retrieval, it is important to assess the FB and its relationship to the airway to explain the cause of impaction. Always try to identify the point of maximal resistance and points of contact that may pose risks for airway trauma during retrieval.

Flexible bronchoscopy is best for these situations because of the ability to navigate and enter distal airways. We recommend using exible

bronchoscopy in combination with a rigid bronchoscope for these situations. Having a secure airway allows for easy exchange of different types of bronchoscopes (pediatric, diagnostic, and therapeutic scopes) and provides a safe environment for unexpected bleeding. Becauseexible bronchoscopy is the only modality that can reach distal airways, exible instruments are used via the working channel of the bronchoscope.

The aim of retrieval in these circumstances is to remove the FB in the path of least resistance with minimal injury to the airway wall and/or displace the FB to a location (i.e. central airway) where retrieval is more feasible. While each FB and patient present with its unique challenges, the following represents general principles that should be considered during retrieval. Topical epinephrine (as previously described) is very useful in minimizing bleeding during the actual removal process. When feasible, the FB should be removed with protection over the sharp aspect of the FB and in a manner to prevent chances of dropping it. This can be achieved by grasping the FB from the sharp edge or by repositioning the FB with the aim of moving the sharp edge to the middle of the lumen. As mentioned earlier, distal positioning of a balloon and in ation can help pull impacted FBs proximally into a more ideal retrieval location when it does not pose the risk of pushing the FB into a worse position during balloon placement. Pulling FBs too proximally is actually undesired, as the FB may move excessively while you are trying to grasp it with forceps. To achieve good control, there must be some resistance to the FB while grasping it. Preferably, you should place it up against a wall which can simplify this process. Remember that for simultaneous use of a balloon and exible bronchoscope, rigid bronchoscopy is recommended. A distally placed balloon can also act as a safeguard to prevent further distal migration of the FB during manipulation and instrumentation, but you need to get it past the FB without dislodging it. The appropriate size balloon should be used also to minimize risk of over-dilation of such relatively small diameter airways which could lead to inadvertent tearing and bleeding.

A small caliber bronchoscope can also be used as an instrument for retrieval. If the bronchoscope can be passed distally to the impacted FB,exion of the distal end of the scope can be used to displace or move the FB proximally. This technique should not be used with any FB that may pose danger or damage to the scope. As stated earlier, if granulation tissue is contributing to the impaction, ablative techniques can be utilized to resect the tissue to detach or “loosen” the FB from the airway wall and allow retrieval.

Iron Pill Aspiration

In this section we will discuss iron pill aspiration, as from our experience and from various case reports, it is well known to be associated with severe airway injury when aspirated. Iron supplementation comes in three different formulations: ferrous sulfate, ferrous gluconate, and ferrous fumarate. Ferrous sulfate is the most common preparation used by patients. Its caustic properties are a direct result of its acidic pH (<3) when dissolved [32] and mixed with bronchial secretions. Consequences of exposure to airway mucosa include intense acute and chronic in ammation, granuloma formation, and eventual fbrosis and bronchostenosis. Radiologically, patients present with fndings consistent with sequelae of retained FBs and airway obstruction such as recurrent pneumonias and atelectasis.

Interestingly, on bronchoscopic examination, iron pills are almost never visualized as they are known to rapidly fragment. Endobronchial biopsy of affected mucosa usually will show iron deposition when stained with Prussian blue stain with associated in ammation (acute and/or chronic). These fndings have been reported even 1 year after the initial pill aspiration event [30]. Also, bronchial washings may demonstrate reactive epithelial cells and histiocytes which may stain positive for iron also. In the relatively acute period, bronchoscopic exam may yield a green-­ brown coating over the bronchial mucosa which represents necrotic debris [33]. A history of pill aspiration and intense bronchial in ammation should raise suspicion for iron formulation aspi-